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Operating Room Resuscitations

William Bromberg brombwi1 at memorialhealth.com
Fri Feb 1 14:17:21 GMT 2008


John,

We are operating in VERY different systems. ACS criteria essentially requires that an OR be available within a few minutes, 24 hours a day, 7 days a week in order to be a level 1 trauma center in the US. This means that if I get a call that a gunshot victim is unstable (or even stable but will obviously need a lap/thoracotomy/whatever) and is 15 minutes out by ambulance I can have an OR available. Now, given that situation why should I stop in the ED?

As has been stated multiple times if you don't have a ready ICU bed or staffed OR immediately available, you have to go to the next best place, i.e. the ED resus room. This is not a failing, it's just a different system and different allocation of resources. 

I still submit to you that in the situation of a hemorrhaging GSW to the abdomen AND with the proviso that there is a ready OR taking the patient to the ED is not only unnecessary but also unwise. What can you do for him there that cannot be done in the OR?

Bill

>>> John Holmes <docjohnholmes at hotmail.com> 2/1/2008 4:37 AM >>>
I really cannot believe the silliness of the proposition that the ED Resus room should be bypassed.  Those of you making such propositions seem to be living in a world of unlimited resources.  In the real world, access to ICUs / ORs etc is usually extremely limited.  In most hospitals the theatre suites are fully booked and the ICUs fully occupied.  Further, in other than the largest centres, these precious resources rarely have immediate manpower available.  By NECESSITY the ED provides acute care, including resuscitation.  Of course it should go without saying that unstable patients who are in need of definitive care - be that in the OR or the angiosuite - should get to those places ASAP.   But many patients in resus rooms do not need hyperurgent definitive intervention.  And this is even more so with non trauma cases.  In fact many do not eventually even require to go to ICU.  The ED provides not only early assessment and treatment but also a gatekeeping role.  
 
In reality the ED HAS developed "far beyond immediate care".  The UK's "4 hour rule" "was politically imposed in the UK and has nothing to do with medical care and everything to do with bureacrats' targets.  It is anathema to those of us who see EM as part of a spectrum of care working seamlessly with the ICU/CCU/OR  etc but NOT excluded or bypassed.
 
John
 
Dr John L Holmes
Director Emergency Medicine Training
AMC & OLVG
Amsterdam
The Netherlands



> Date: Thu, 31 Jan 2008 22:26:12 +0000> From: atacc.doc at btinternet.com> To: trauma-list at trauma.org> Subject: Re: Operating Room Resuscitations> > Matt, Ken, Errington, Ron etc,> What music to me ears.....for years we have being tying to pry patients out of the claws of the resus room. Sadly, whilst the paramedics no longer 'stay and play' we have simply moved the problem to the resus room! Drips, level one infusors, excessive investigations and so it goes on......surely the role of the ER is rapid triage, commence life saving care and GO!! > > In the UK we have a 4 hour target for patients to leave the Emergency Dept. Incredibly, this also applies to the resus room.....4 hours!! If any patient needs for hours to commence resus or to organise further care then there is something very wrong with the system yet day after day we get patients referred to the ICU after 3hrs 50 mins who are far from sorted.....stay and play stikes again!> > What's worse is the fact that we constantly hear how they cannot make the target time and the departments are so busy. Surely by rapidly dispatching the sickest and most dependent patients then they can get on with managing all those others still waiting?> > Can we just get a good triage sister, make a decision about the route of dispatch and then get them off to theatre, ICU, angio, all within minutes? Well, Ken and his team clearly demonstrate that you can!> > In ICU if we have a critically ill patient that has active life threatening bleeding then we immediately request consultant level support from all relevant specialities, we don't haplessly struggle on for hour after hour until it is too late.> > EM has an important role to play in every hospital, but how much should they paly in major trauma or critical illness? Has the role of EM grown too far beyond immediate care?> > Regards> Mark F> UK> > > > > ----- Original Message ----> From: Matthew Reeds <mgreeds at reeds.uk.com>> To: trauma-list at trauma.org> Sent: Thursday, 31 January, 2008 12:05:49 PM> Subject: Operating Room Resuscitations> > > I agree Errington. I would in fact go further by saying that the ICU/HDU is THE ONLY place for patients who need resuscitation but DON'T need> the operating room (unless they are going to interventional radiology for embolisation etc.) > Further to Ken's comment on the role of the A&E/ED department "waving to the patient", this I fully agree with and wholeheartedly support. However I would say that the A&E does actually have ONE useful purpose - for the receptionist to book the patient into the hospital. They can also ensure that the order for massive transfusion packs is made IMMEDIATELY for them to be sent STRAIGHT to theatre/OR for the patient (for those hospitals that implement the 1:1 transfusion protocol.) I'll happily conceed that this is in fact two purposes.> Matthew> ____________________________________________________________> KMATTOX at aol.com KMATTOX at aol.com > Thu Jan 31 03:26:29 GMT > BINGO. Great point. For any trauma patient that is not going to be > able to be dismissed from the ER following minor treatment for a minor injury, > there is NO REASON TO KEEP THAT PATIENT IN THE ER ANY LONGER THAN IT TAKES TO > COMPLETE THE LOGISTICS OR PAPERWORK TO GET THEM TO THE OR, ICU, FLOOR, IR, > OR OTHER LOCATION. > > Kenneth L. Mattox, MD> Houston> > > In a message dated 1/30/2008 9:23:48 P.M. Central Standard Time, > errington at erringtonthompson.com writes:> > The ICU is a great place for patients who need resuscitation but DON'T need> the operating room. > > E> ____________________________________________________________> In a message dated 1/30/2008 9:23:48 P.M. Central Standard Time, > errington at erringtonthompson.com writes:> I would add that those patient that don't need to go to the OR but still> need significant resuscitation maybe better in the ICU than the ER or> anywhere else. For the most part trauma surgeons run their own ICU's.> These are the nurses that have heard your lectures. They come to your> conferences. They know what you want. > > The ICU is a great place for patients who need resuscitation but DON'T need> the operating room. > > E> > Errington C. Thompson, MD, FACS, FCCM> Trauma/Surgical Critical Care> Author - Letter to America> Asheville, NC> > -----Original Message-----> From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]> On Behalf Of Ronald Gross> Sent: Wednesday, January 30, 2008 6:52 AM> To: trauma-list at trauma.org> Subject: Re: Operating Room Resuscitations> > Yeah - what HE said! ;-)> > Matt, you and I are on the same page here - but you said it far better than> I did - Thanks!> > Take care,> Ron> > >>> Matthew Reeds <mgreeds at reeds.uk.com> 1/30/2008 5:27 AM >>>> > Mike & Ron,> When pontificating over the treatment that I give to any patient, I always> try to ask what I would want for myself and apply this to give the best> treatment to each patient. I would NOT want to be in an A&E/ED resuscitation> room but would "rather" be in either theatre/OR, ITU/HDU, the ward or> radiology (depending upon my injury) having the proper treatment that I> need. This is what I would strive for with any of my patients.> Therefore I see NO reason for the patient to remain in A&E/ED for> resuscitation. As Ron says, if the patient needs surgery, then off to> theatre/OR they go. If they need non-operative resuscitation, then off to> ITU or HDU they go for the care required. [This frees up theatre/OR> resources and time as Mike says if surgery is not required for better> utilisation.] Radiology resuscitation is ONLY required for THERAPEUTIC> intervention such as angio for pelvic haemorrhage and stabilisation (if the> extra-peritoneal pelvic packing approach is NOT used etc.)> >From my experience, there is NO need/role for A&E/ED resuscitation - if the> patient is that sick, then they need to be elsewhere (e.g. theatre/OR,> ITU/HDU etc.)> Even for major haemorrhage that requires surgery, these UNSTABLE patients> SHOULD be rapidly transported to theatre/OR for surgery for emergency> treatment. I would NOT NORMALLY advocate A&E/ED operating UNLESS absolutely> necessary which has happened to me on a couple of occasions [such as cardiac> arrest secondary to IVC transection at the bifurcation from multiple stab> wounds from a bayonet in a 19 year old male.] He had been "down" for 3 mins> when he arrived in A&E by paramedics/EMT and there was no way we could> transfer him to theatre/OR on the top floor (11th floor) and at the other> end of the hospital to save him - a fault of the hospital design. Therefore> we performed a laparotomy in the A&E/ED resus room and got him back with> RAPID abdominal packing and then transferred to theatre just as rapidly.> However, this should be a RARE occasion and ONLY be absolutely necessary to> imminently save life rather than be the norm. In essence this comes down to> clinical acumen, experience and ability of the clinician to use sound> judgment and I agree with Mike, that if the patient doesn't need surgery,> then theatre/OR is not the best place to resuscitate the patient - they> should be in the ITU/HDU instead.> > Matthew> Surgery U.K.> --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> http://www.trauma.org/index.php?/community/-- 
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